CENTERS FOR DISEASE CONTROL AND PREVENTION

HEPATITIS

 SURVEILLANCE

REPORT NUMBER 57

Issued September 2000

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES • Public Health Service

HIGHLIGHTS

Diagnostic testing for hepatitis E

virus infection

Diagnostic testing for agents of

non-A-E hepatitis

Internet access to CDC viral hepatitis

information

National surveillance through 1995
Preface

This report summarizes information from state health departments, university investigators,

virology laboratories, and other pertinent sources, domestic and foreign, about acute viral

hepatitis. Much of the information is preliminary. It is intended primarily for persons

responsible for disease control. Contributions to the Hepatitis Surveillance Report are most

welcome; send them to:

Chief, Viral Hepatitis Surveillance

Hepatitis Branch, Mailstop G37

Division of Viral and Rickettsial Diseases

National Center for Infectious Diseases

Centers for Disease Control and Prevention

Atlanta, GA 30333

Suggested Citation

Hepatitis Surveillance Report No. 57.

Atlanta: Centers for Disease Control and Prevention, 2000. 38 p.

Centers for Disease Control and Prevention Jeffrey P. Koplan, M.D., M.P.H., Director

National Center for Infectious Diseases James M. Hughes, M.D., Director

Division of Viral and Rickettsial Diseases James W. LeDuc, Ph.D., Acting Director

Hepatitis Branch Harold S. Margolis, M.D., Chief

Epidemiology Section Miriam J. Alter, Ph.D., Chief

Surveillance Unit Eric E. Mast, M.D., M.P.H., Chief

Annemarie Wasley, Sc.D, Epidemiologist

Office of Health Communication Meredith Hickson, M.P.H, Chief

Ann Mather, M.Ed., Technical Editor

Epidemiology Program Office Steven B. Thacker, M.D., M.Sc., Director

Division of Public Health Surveillance

and Informatics Denise T. Koo, M.D., M.P.H., Acting Director

Surveillance Systems Branch Sam Groseclose, D.V.M., Chief

Acknowledgments: Special contributions to this report were made by Eric Mast. Special thanks

to Carlisle Quantrell for programming and computer support and to Karoyle L. Colbert for

producing the desktop publishing version. In addition, special thanks to Pat Coleman for his

work in preparing this report.
HEPATITIS

Surveillance

Hepatitis Surveillance iii

Contents

Page

I. Introduction ..............................................1

II. Issues and Answers .........................................3

What diagnostic tests for hepatitis E virus infection are available?..................3

What diagnostic tests for agents of acute non-A-E hepatitis are available? .............3

III. New Horizons.............................................4

Internet Access to CDC Viral Hepatitis Information .........................4

Hepatitis Branch Home Page (http://www.cdc.gov/hepatitis).....................4

IV. National Surveillance for Acute Viral Hepatitis Through 1995 ..................5

Reported Cases of Acute Viral Hepatitis, by Type and Year, United States .............6

Hepatitis A ..............................................9

Hepatitis B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Hepatitis C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Methods and Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Case Definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
iv Hepatitis Surveillance

Figures

Page

Figure IV-1. Hepatitis A by Year, United States, 1952-1995.......................6

Figure IV-2. Reported Cases of Hepatitis A, by Region, United States, 1975-1995...........7

Figure IV-3. Reported Cases of Hepatitis A by County, United States, 1995..............8

Figure IV-4. Reported Cases of Hepatitis A by Age, United States, 1983-1995.............9

Figure IV-5. Trends in Selected Risk Factors for Patients Reported with Hepatitis A,

by Mutually Exclusive Groups, United States, 1983-1995 . . . . . . . . . . . . . . . . 13

Figure IV-6. Hepatitis B by Year, United States, 1966-1995 . . . . . . . . . . . . . . . . . . . . . . 14

Figure IV-7. Reported Cases of Hepatitis B, by Region, United States, 1975-1995 . . . . . . . . . . 15

Figure IV-3. Reported Cases of Hepatitis B per 100,000 Population, United States, 1995 . . . . . . 16

Figure IV-9. Reported Cases of Hepatitis B, by Age, United States, 1983-1995. . . . . . . . . . . . 17

Figure IV-10. Trends in Selected Risk Factors for Males Reported with Hepatitis B,

by Mutually Exclusive Groups, Selected States, 1983-1995 . . . . . . . . . . . . . . . 21

Figure IV-11. Trends in Selected Risk Factors for Females Reported with Hepatitis B,

by Mutually Exclusive Groups, Selected States, 1983-1995 . . . . . . . . . . . . . . . 21

Figure IV-12. Estimated Incidence of Acute Hepatitis C, United States, 1982-1995 . . . . . . . . . . 23

Figure IV-13. Trends in Selected Risk Factors for Patients Reported with Hepatitis

C/NANB, by Mutually Exclusive Groups, Selected States, 1983-1995 . . . . . . . . . . 27

Figure IV-14. Risk Factors Associated with Reported Cases of Acute Hepatitis C

in Sentinel Counties, United States, 1991-1995 . . . . . . . . . . . . . . . . . . . . . 28
Hepatitis Surveillance v

Tables

Page

Table IV-1. Reported Cases of Acute Viral Hepatitis, by Type and Year,

United States, 1966-1995 .................................5

Table IV-2. Clinical Characteristics of Patients Reported with Hepatitis A by

Age-Group, United States, 1994-1995 . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Table IV-3. Reported Cases of Hepatitis A by Age, Sex, and Race/Ethnicity,

United States, 1994-1995 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Table IV-4. Epidemiologic Characteristics during the 2 to 6 Weeks Prior to Illness of

Patients Reported with Hepatitis A, by Age-Group, United States, 1994-1995 . . . . . . 12

Table IV-5. Distribution of Hepatitis B by Age, Sex, and Race/Ethnicity, United States, 1994-95. . . 18

Table IV-6. Clinical Characteristics of Patients Reported with Hepatitis B, by

Age-Group, United States, 1994-1995 . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Table IV-7. Epidemiologic Characteristics of Patients Reported with Hepatitis B,

by Age-Group, United States, 1994-1995. . . . . . . . . . . . . . . . . . . . . . . . . 20

Table IV-8. Reported Cases of Hepatitis C/NANB by Age, Sex, and Race/Ethnicity,

United States, 1994-1995 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Table IV-9. Clinical Characteristics of Patients Reported with Hepatitis C/Non-A,

Non-B Hepatitis, by Age-Group, United States, 1994-1995. . . . . . . . . . . . . . . . 25

Table IV-10. Epidemiologic Characteristics of Patients Reported with

Hepatitis C/Non-A, Non-B Hepatitis, by Age-Group, United States, 1994-1995 . . . . . 26

Table IV-11. Cases Reported to Viral Hepatitis Surveillance Program Compared

with NNDSS, by Type of Submission, 1994-1995. . . . . . . . . . . . . . . . . . . . . 29

Table IV-12. Proportion of Total Reported Cases Including VHSP Risk Factor Data,

by States, 1995 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

I. Introduction

With this issue, we are introducing a revised

format for our description of surveillance data,

which focuses on presentation of data with figure

and tables and limited text. We invite readers to

send us comments (see Preface for address). A copy

of this report is available on the CDC Internet site at

http://www.cdc.gov/hepatitis.

This report summarizes surveillance data

collected during 1994-1995 for acute viral hepatitis.

With a total of 46,963 cases reported to CDC in 1995,

acute viral hepatitis was exceeded only by AIDS

(71,547 cases), chlamydia (477,638 cases), gonorrhea

(392,848 cases), and syphilis (68,953 cases) among

reportable diseases in the United States. After

declining from 1989-1993, the overall case count has

increased from 1994-1995 as a result of a cyclic

increase in hepatitis A. In 1995, a total of 31,582

cases of hepatitis A were reported, which was the

highest yearly total since 1989. Hepatitis B has

declined steadily since 1985.

The objective of national surveillance of acute

viral hepatitis is to provide serologic, demographic,

and epidemiologic information that will aid in

formulating strategies and policies for the prevention and control of these diseases. The hepatitis

surveillance report interprets and disseminates this

information, presents new developments in the

field, and clarifies issues related to viral hepatitis.

Nationwide information on hepatitis is obtained

by two surveillance systems. In one, incidence data

are collected from cases reported to the CDC

National Notifiable Diseases Surveillance System

(NNDSS) by each state and territory. The etiologic

classification is made by physician diagnosis; confirmation by serologic testing is not required. The

number of cases and date reported of hepatitis A,

hepatitis B and hepatitis C/non-A, non-B appear in

the Morbidity and Mortality Weekly Report (MMWR)

and the MMWR Annual Summary of Notifiable

Diseases, and are summarized in this report as well.

In the other system, clinical, serologic and

epidemiologic data pertaining to risk factors for

disease acquisition are obtained from the Viral

Hepatitis Surveillance Program (VHSP), a separate

reporting system operated by the Hepatitis Branch,

Division of Viral and Rickettsial Diseases, National

Center for Infectious Diseases, CDC, Atlanta, Georgia. The VHSP obtains its information from the viral

hepatitis case record, a copy of which appears in the

Appendix. This form (CDC 53.1) can be obtained

from the Hepatitis Branch. In addition, in 1991

several states began submitting their case reports via

electronic surveillance through the National Electronic Telecommunications System for Surveillance

(NETSS). By 1995, 67% of VHSP cases were submitted electronically. For states interested in using

NETSS to report hepatitis case investigations (core

data plus extended record for serologic and risk

factor data), the Hepatitis Branch and CDC’s Epidemiology Program Office will provide technical

support.

A third surveillance system referenced in this

report is the Sentinel Counties Study of Acute Viral

Hepatitis, a more intensive study of viral hepatitis in

six counties representative of the United States as a

whole. This surveillance system has provided

nationally representative data on acute viral hepatitis since 1982, and has been a resource for detecting

emerging infections and performing more in-depth

studies. Data from the Sentinel Counties have been

included for comparison with the other surveillance

systems in this issue.

Surveillance data such as those reported here are

dependent on the cooperation of state and local

health departments, public health practitioners, and

medical care persons reporting the diseases from

their hospitals, clinics, and offices. In 1995, some 20

states reported VHSP data on at least 60% of their

total cases.

CDC’s ability to accurately analyze and interpret

nationwide trends and patterns, identify high-risk

groups, and determine mechanisms of transmission

for each type of hepatitis depends on the cooperation of the state and local health departments in

reporting laboratory and epidemiologic data to the

VHSP. Key to these tasks is the accurate determination of the specific agent causing the viral hepatitis.

Five distinct agents are responsible for viral hepatitis diseases worldwide; four have been identified as

endemic in the United States: hepatitis types A, B, C,

and D. The last type, Delta hepatitis, is not a reportable disease in the United States, and occurs only as

a coinfection or superinfection with hepatitis B

virus.

Hepatitis E virus (HEV) is the major etiologic

agent of enterically transmitted, non-A, non-B hepatitis worldwide. Hepatitis E is most commonly

recognized to occur in outbreaks associated with

fecally contaminated drinking water. In many areas

in which hepatitis E outbreaks have been reported,

Hepatitis Surveillance 1
HEV infection accounts for a substantial proportion

of acute sporadic hepatitis in both children and

adults. Virtually all cases of acute hepatitis E in the

United States have been reported among travelers

returning from high HEV-endemic areas. Recently,

however, several cases of clinical acute hepatitis E

have been reported among persons with no history

of travel outside the United States.

The hepatitis G virus (HGV) and TT virus (TTV)

are agents recently identified in patients with viral

hepatitis. However, studies conducted to date have

shown no association between these agents and

acute or chronic hepatitis.

We thank those who have been actively contributing to the viral hepatitis surveillance program

and encourage others to participate.

2 Hepatitis Surveillance

I. Introduction
II. Issues and Answers

What diagnostic tests for hepatitis E virus infection are available?

In the United States, hepatitis E is rare, and most

reported cases have been associated with travel to

HEV-endemic regions (1, 2). However, several cases of

acute hepatitis E have been reported among persons

with no recent history of travel outside the United

States (3, 4). In addition, a new virus has recently been

discovered in pigs in the United States that is closely

related to human HEV isolates, which raises the possibility of zoonotic transmission of HEV (5).

HEV infection should be considered in patients

with signs and symptoms of acute viral hepatitis

who are negative for serologic markers of acute

hepatitis A (immunoglobulin M [IgM] antibody to

hepatitis A virus), acute hepatitis B (IgM antibody to

hepatitis B core antigen), and hepatitis C (antibody

to hepatitis C virus). No serologic tests for hepatitis

E are commercially available in the United States,

but serologic assays that detect IgM-and IgG-specific

antibody to HEV and polymerase chain reaction

tests that detect HEV RNA are available in research

laboratories. Health-care professionals who need

information on serologic testing of persons with

evidence of acute non-ABC hepatitis may contact

CDC’s Hepatitis Branch, Division of Viral and

Rickettsial Diseases, National Centers for Infectious

Diseases, telephone (404) 371-5910.

References

1. De Cock KM, Bradley DW, Sandford NL, et al.

Epidemic non-A, non-B hepatitis in patients

from Pakistan. Ann Intern Med

1987;106:227-30.

2. Centers for Disease Control and Prevention.

Hepatitis E among U.S. travelers, 1989-1992.

MMWR 1993; 42:1-4.

3. Kwo PY, Balan VJ, Carpenter HA, et al. Acute

hepatitis E acquired in the United States.

Hepatology 1995;22:182A (abstract 304).

4. Munoz SJ, Bradley DW, Martin P, Krawczynski

K, Purdy MA, Westerbarg S. Hepatitis E virus

found in patients with apparent fulminant

non-A, non-B hepatitis. Hepatology

1992;16:76A (abstract 128).

5. Meng XJ, Purcell RH, Halbur PG, et al. A novel

virus in swine is closely related to the human

hepatitis E virus. Proc Natl Acad Sci USA

1997;94:9860-5.

What diagnostic tests for agents of acute non-A-E hepatitis are available?

Recently two isolates of a new virus designated

hepatitis G virus (HGV) or hepatitis GB virus C

(GBV-C) were identified in patients with viral hepatitis (6,7). In addition, a new virus named TT virus

(TTV) was identified in patients with

post-transfusion hepatitis and in patients with

chronic liver disease of unknown etiology (8). Both

of these viruses appear to be transmitted by transfusion; however, studies conducted to date have not

implicated either of these viruses as an agent of

acute or chronic hepatitis (8,9). No tests for HGV

(GBV-C) or TTV infection are commercially available in the United States, but polymerase chain reaction tests that detect nucleic acid of these viruses are

available in research laboratories. Until further studies demonstrate that these, or other viruses, are a

cause of acute or chronic viral hepatitis and suitable

diagnostic tests are developed, testing for these

agents will not be routinely performed in the CDC’s

Hepatitis Branch Laboratory.

References

6. Linnen J, Wages J Jr, Zhang-Keck ZY, et al.

Molecular cloning and disease association of

hepatitis G virus: a transfusion-transmissible

agent. Science 1996;271:505-8.

7. Simons JN, Leary TP, Dawson GJ, et al.

Isolation of novel virus-like sequences

associated with human hepatitis. Nat Med

1995;1:564-9.

8. Okamoto H, Nisizawa T, Kato N, et al.

Molecular cloning and characterization of a

novel DNA virus (TTV) associated with

posttransfusion hepatitis of unknown etiology.

Hepatol Res 1998;10:1-16.

9. Alter MJ, Gallagher M, Morris TT, et al. Acute

non-A-E hepatitis in the United States and the

role of hepatitis G virus infection. N Engl J

Med 1997;336:741-6.

Hepatitis Surveillance 3
III. New Horizons

Internet Access to CDC Viral Hepatitis Information

In recent years, public health practitioners,

epidemiologists and state and local health department personnel have taken advantage of the Internet

to create easy and timely access to information critical to the public health, including surveillance data

on reported diseases. CDC provides Internet access

to public documents, tables, and data sets for downloading via the CDC home page

(http://www.cdc.gov) and links to CDC

program-specific sites. The following provides a

brief description of the information accessible

through the Hepatitis Branch Internet site and the

current Internet browser address. Check Internet

sites frequently; new information is posted on a

regular basis.

Hepatitis Branch Home Page (http://www.cdc.gov/hepatitis)

The Hepatitis Branch home page provides recent

documents, brochures, announcements, and slide

sets, as well as the toll-free number for accessing

information on viral hepatitis . Links to information

specific to each type of viral hepatitis are provided,

including fact sheets, frequently asked questions,

disease burden details, and recommendations

(usually published in the MMWR).

To provide access to documents directly, the

Home Page provides a link titled “Resource Center.”

Clicking on this link will open a page listing surveillance reports, slide sets, MMWR articles containing

recommendations and guidelines, brochures, and

other items. For those looking for additional information on viral hepatitis, links to other sites including —the National Digestive Diseases Information

Clearinghouse, the National Institutes of Health and

non-governmental organizations— are provided on

this page.

If you have any questions or comments on the

Hepatitis Branch Internet site, or have suggestions

for additional information or links, please send them

to Chief, Viral Hepatitis Surveillance, Hepatitis

Branch, CDC, 1600 Clifton Road, Mail Stop G37,

Atlanta, GA 30333
IV. National Surveillance for Acute

Viral Hepatitis through 1995

Hepatitis Surveillance 5

Types of Hepatitis

Hepatitis A Hepatitis B Hepatitis C/NANB* Unspecified Total

Year No. Rate** No. Rate No. Rate No. Rate No. Rate

1966 32,859 16.77 1,497 0.79 *** *** † † 34,356 17.56

1967 38,909 19.67 2,458 1.28 *** *** † † 41,367 20.95

1968 45,893 22.96 4,829 2.49 *** *** † † 50,722 25.45

1969 48,416 23.98 5,909 3.02 *** *** † † 54,325 27.00

1970 56,797 27.87 8,310 4.08 *** *** † † 65,107 31.95

1971 59,606 28.90 9,556 4.74 *** *** † † 69,162 33.64

1972 54,074 25.97 9,402 4.52 *** *** † † 63,476 30.49

1973 50,749 24.18 8,451 4.03 *** *** † † 59,200 28.21

1974 40,358 19.54 10,631 5.15 *** *** 8,351 3.95 59,340 28.07

1975 35,855 16.82 13,121 6.30 *** *** 7,158 3.44 56,134 26.34

1976 33,288 15.51 14,973 7.14 *** *** 7,488 3.57 55,749 25.97

1977 31,153 14.40 16,831 7.78 *** *** 8,639 3.99 56,623 26.17

1978 29,500 13.53 15,016 6.89 *** *** 8,776 4.02 53,292 24.44

1979 30,407 13.82 15,452 7.02 *** *** 10,524 4.79 56,393 25.62

1980 29,087 12.84 19,015 8.39 *** *** 11,894 5.25 59,996 26.49

1981 25,802 11.25 21,152 9.22 *** *** 10,975 4.79 57,929 25.26

1982 23,403 10.11 22,177 9.58 2,629 1.14 8,564 3.40 56,773 24.52

1983 21,532 9.20 24,318 10.39 3,470 1.48 7,149 3.05 56,469 24.12

1984 22,040 9.33 26,115 11.06 3,871 1.64 5,531 2.34 57,557 24.37

1985§ 23,257 10.04 26,654 11.51 4,192 1.81 5,530 2.39 59,633 25.76

1986§ 23,430 10.02 26,107 11.17 3,634 1.55 3,940 1.69 57,111 24.43

1987 25,280 10.39 25,916 10.65 2,999 1.23 3,102 1.27 57,297 23.54

1988 28,507 11.59 23,177 9.42 2,619 1.07 2,470 1.00 56,773 23.10

1989 35,821 14.43 23,419 9.43 2,529 1.02 2,306 0.93 64,075 25.81

1990 31,441 12.64 21,102 8.48 2,553 1.03 1,671 0.67 56,767 22.81

1991 24,378 9.67 18,003 7.14 3,582 1.42 1,260 0.50 47,223 18.73

1992 23,112 9.06 16,126 6.32 6,010 2.36 884 0.35 46,132 18.09

1993 24,238 9.39 13,361 5.18 4,786 1.86 627 0.24 43,012 16.68

1994 26,796 10.29 12,517 4.81 4,470 1.78 444 0.17 44,227 17.05

1995 31,582 12.02 10,805 4.16 4,576 1.76 ‡ ‡ 46,963 18.00

* Number and rates shown for hepatitis C/Non-A, non-B hepatitis are unreliable-see note p. xx of this report.

** Rate per 100,000 population

*** Not reported until 1982

† Not reported until 1974

§ Excludes cases from New York City; data not available for 1985 or 1986.

‡ No longer reported as of 1995.

Source: National Notifiable Diseases Surveillance System

Table IV-1. Reported Cases of Viral Hepatitis, by Type and Year, United States, 1966-1995
6 Hepatitis Surveillance

IV. National Surveillance for Acute Viral Hepatitis through 1995

Hepatitis A

Hepatitis A incidence varies cyclically, with an interepidemic period of 7 to 10 years. The most recent increase, which

began in 1993, continued through 1995, when a total of 31,582 cases were reported.

0

5

10

15

20

25

30

35

40

45

1952 1955 1958 1961 1964 1967 1970 1973 1976 1979 1982 1985 1988 1991 1994

Year

Reported

Cases per 100,000 Population

All Types

Hepatitis A

Figure IV-1. Hepatitis A by Year, United States, 1952-1995

Source: National Notifiable Diseases Surveillance System
The incidence of hepatitis A varies regionally: rates in

the West are 2-5 times higher than in the rest of the

nation. The underlying reason for these differences has

not been determined; the regions do not differ substantially with respect to the distribution of known risk

factors. However, higher incidence rates in the West do

correlate with demographic factors (e.g., counties with

10% or more of the population classified as American

Indian had average rates 3.5 times higher than counties

where less than 10% of the population are American Indians; counties with 15% or more of the population classified as Hispanic had average rates 2.1 times higher than

counties with less than 15% classified Hispanic).

Hepatitis Surveillance 7

IV. National Surveillance for Acute Viral Hepatitis through 1995

0

5

10

15

20

25

30

35

40

1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995

Year

Cases per 100 000 Population ,

Northeast

Southeast

Midwest

West

Figure IV-2. Reported Cases of Hepatitis A, by Region, United States, 1975 - 1995

Source: National Notifiable Diseases Surveillance System
8 Hepatitis Surveillance

IV. National Surveillance for Acute Viral Hepatitis through 1995

States in the West have a higher proportion of

counties with moderate-to-high hepatitis A rates.

Children living in states or communities including

counties or groups of counties that have hepatitis A

rates consistently higher than the national average

should be vaccinated. In states where the average

annual hepatitis A rate over the past 10 years was at

least 20/100,000 (i.e., approximately twice the

national average), routine vaccination of children is

recommended; in addition, it should be considered

in states where the average annual rate for the same

period while less than 20/100,000 was as at least

10/100,000. (MMWR 1999: 48[No. RR-12])

AM. SAMO

CNMI

GUAM

PR

VI

DC

GUAM

NYC

PR

VI

RATE per 100,000 <10 10-19 ≥ 20

Figure IV-3. Reported Cases of Hepatitis A by County, United States, 1995

Source: National Notifiable Diseases Surveillance System
Hepatitis Surveillance 9

IV. National Surveillance for Acute Viral Hepatitis through 1995

The incidence rates of acute hepatitis A are substantially higher in persons less than 40 years of age than for older

age-groups. However, the incidence rates for different age-groups among persons under 40 are similar: no single

age-group predominates. The incidence of hepatitis A varies cyclically in all age-groups.

0

5

10

15

20

25

1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995

Year

Casesper 100,000 Population

15-24 yrs

25-39 yrs

<15 yrs

40+ yrs

Figure IV-4. Reported Cases of Hepatitis A by Age, United States, 1983-1995

Source: National Notifiable Diseases Surveillance System
Clinical Characteristics

The overall rate of hospitalization of patients with hepatitis A was similar to that of previous years (18.5% to 20.4% for

1990-1993) and the overall case-fatality rate was less than 1%. The rate of hospitalization and the case-fatality rate for

hepatitis A patients both increase with increasing age.

10 Hepatitis Surveillance

IV. National Surveillance for Acute Viral Hepatitis through 1995

Percentage of Patients by Age (years)*

1994

Total

N=11,741

<1-14

N=3,638

15-39

N=5,610

40

N=2.386

Jaundice 84.8 84.5 86.8 80.4

Hospitalized for hepatitis 17.9 8.9 18.7 29.5

Death as a result of hepatitis 0.8 0.1 0.8 1.7

1995 N=14,229 N=3,426 N=7,887 N=2,762

Jaundice 83.6 80.6 86.3 79.6

Hospitalized for hepatitis 19.4 9.3 20.3 28.8

Death as a result of hepatitis 0.3 0.1 0.3 0.8

Table IV-2. Clinical Characteristics of Patients Reported with Hepatitis A, by Age-Group, United States,

1994-1995

* Percentages exclude patients with missing data for age (2% of total), jaundice (14%-17% of total), hospitalization

(15%-16% of total), and death (19% of total).

Source: Viral Hepatitis Surveillance Program, CDC.
Hepatitis Surveillance 11

IV. National Surveillance for Acute Viral Hepatitis through 1995

Demographic Characteristics

As in previous years,

 children and adolescents (<20 years of age) accounted for approximately one-third cases in both

1994 and 1995,

 a higher proportion of cases occurred among males than among females, and

 the majority of cases occurred in non-Hispanic whites.

1994

N=11,741

1995

N=14,229

CHARACTERISTIC No. %* No. %*

Age (Years)

<5 792 6.8 724 5.1

5-9 1,754 15.1 1,596 11.3

10-14 1,100 9.4 1,106 7.8

15-19 918 7.9 1,146 8.1

20-29 2,526 21.7 3,688 26.1

30-39 2,175 18.7 3,053 21.6

40-49 1,136 9.7 1,477 10.5

50-59 506 4.3 605 4.3

60+ 745 6.4 715 5.1

Sex

Male 6,494 56.0 7,975 56.7

Female 5,093 44.0 6,078 43.3

Race/Ethnicity

White, non-Hispanic 6,786 62.3 8,736 68.6

Black, non-Hispanic 1,026 9.4 1,450 11.4

Hispanic 1,378 12.7 1,309 10.3

American Indian or Alaskan Native 1,477 13.6 1,061 8.3

Asian or Pacific Islander 217 2.0 180 1.4

Table IV-3. Reported Cases of Hepatitis A by Age, Sex, and Race/Ethnicity, United States, 1994-95

*A total of 11,741 and 14,229 cases of hepatitis A were reported to VHSP in 1994 and 1995 respectively. Percentages in this table

exclude patients with missing data.

Source: Viral Hepatitis Surveillance Program, CDC.
12 Hepatitis Surveillance

IV. National Surveillance for Acute Viral Hepatitis through 1995

Risk factor analysis

Among cases for whom a risk factor was identified, contact with another person with hepatitis A

was overall the most frequently identified risk

factor. Among cases occurring in persons less than

15 years of age, attending day-care was the most

frequently identified risk factor, and for cases in

persons 15-39 years of age, contact with a day-care

child or employee was the 2nd most commonly identified risk factor. However, information is not

routinely collected to determine whether the

day-care contact is infected with hepatitis A virus,

and although day-care centers might be the source

of outbreaks of hepatitis A within some communities, disease within day-care centers more commonly

reflects extended transmission in the community.

International travel was reported for 7% of hepatitis A cases in 1995. Of these travel-related cases,

51% were associated with trips to South and Central

America and 11% to travel in Asia and the South

Pacific. Some 70% of these travel-related hepatitis

A cases were associated with trips of more than 7

days, 15% were associated with trips of 4-7 days,

and 15% were associated with trips of <3 days.

Among cases associated with travel of less than 4

days’ duration, 90% involved travel to

South/Central America.

Nearly one-half of hepatitis A case-patients in

both 1994 and 1995 reported no known risk factor.

However, evidence from epidemiologic studies indicates that asymptomatic infections, particularly in

children, play an important role as unrecognized

sources of infection.

Percentage of Patients by Age (years)**

1994 Total <1-14 15-39 40

N = 11,741 N = 3,638 N = 5,610 N = 2,386

Child/employee in day-care center 7.8 18.2 3.3 2.4

Contact of day-care child/employee 8.3 7.3 10.2 5.1

Sexual contact with hepatitis A patient 1.8 0.0 2.8 2.1

Household contact of hepatitis A patient 7.8 11.3 6.7 5.0

Other contact of hepatitis A patient 10.6 13.5 10.7 6.0

Suspected food- or waterborne outbreak 2.6 1.7 2.7 4.1

International travel 7.3 6.0 7.6 8.4

Homosexual activity 4.7 0.5 8.3 3.3

Injection drug use 3.2 0.1 7.3 2.5

Unknown 45.9 41.4 40.4 59.9

1995 N=14,229 N=3,425 N=7,885 N=2,797

Child/employee in day-care center 6.1 17.1 2.2 3.0

Contact of day-care child/employee 8.7 8.2 9.9 6.1

Sexual contact with hepatitis A patient 2.4 0.1 3.5 2.1

Household contact of hepatitis A patient 8.8 13.8 7.8 5.6

Other contact of hepatitis A patient 11.3 10.9 12.7 8.0

Suspected food- or waterborne outbreak 2.2 1.3 2.5 2.5

International travel 6.8 7.7 6.0 7.9

Homosexual activity 5.1 0.8 6.6 5.3

Injection drug use 5.0 0.1 7.8 3.4

Unknown 43.6 40.1 41.0 56.1

* Mutually exclusive groups, in decreasing order of most probable source.

**A total of 11,741 and 14,229 cases of hepatitis A were reported to VHSP in 1994 and 1995 respectively. Percentages in this table

exclude patients with missing risk factor data.

Table IV-4. Epidemiologic Characteristics* during the 2 to 6 Weeks Prior to Illness of Patients

Reported with Hepatitis A, by Age-Group, United States, 1994-1995

Source: Viral Hepatitis Surveillance Program, CDC.
Hepatitis Surveillance 13

IV. National Surveillance for Acute Viral Hepatitis through 1995

Cyclical increases in hepatitis A in the 1980s and

1990s have been primarily associated with an

increase in cases among persons with personal

contact with another person with hepatitis A, and an

increase in cases associated with child day-care. The

increase in hepatitis A incidence from 1994-1995 has

been associated with an increase in cases among

men who have sex with men, and among injecting

drug users with outbreaks among these groups

reported in several states. The number of cases associated with common-source outbreaks is relatively

small (<500) and remained stable during 1983-1995.

Similar trends in risk factors for hepatitis A were

found in data from the Sentinel Countries Study of

Viral Hepatitis. However, in contrast to the VHSP

data, Sentinel Counties data show no appreciable

increase in day-care-associated or foreign

travel-associated hepatitis A for 1994-1995.

0

500

1000

1500

2000

2500

3000

3500

4000

1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995

Number of cases

Contact with Hep A case

Day-Care

Foreign Travel Homosexual Activity

Drug Use

Outbreak

Figure IV-5. Trends in Selected Risk Factors for Patients Reported with Hepatitis A, by Mutually

Exclusive Groups, United States, 1983-1995

Source: Viral Hepatitis Surveillance Program, CDC.
14 Hepatitis Surveillance

Hepatitis B

Hepatitis B incidence increased from 1966 through 1985. This increase was at least partially due to increased use of

serologic testing and also to erroneous reporting of chronically infected persons. From 1985 to 1995, the incidence of

hepatitis B declined by more than 60%.

0

2

4

6

8

10

12

14

1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995

Year

Cases per 100,000 Population

Figure IV-6. Hepatitis B by Year, United States, 1966-1995

Source: National Notifiable Diseases Surveillance System
In recent years, incidence rates across the United States have declined. They are now similar in all regions.

Hepatitis Surveillance 15

IV. National Surveillance for Acute Viral Hepatitis through 1995

0

5

10

15

20

1976 1978 1980 1982 1984 1986 1988 1990 1992 1994

Year

Cases per 100,000 Population

West

Southeast

Midwest

Northeast

Figure IV-7. Reported Cases of Hepatitis B, by Region, United States, 1975-1995

Source: National Notifiable Diseases Surveillance System
16 Hepatitis Surveillance

IV. National Surveillance for Acute Viral Hepatitis through 1995

8.0 - < 12.0 12.0 +

NYC

DC

PR

VI

GUAM

n.a. AM SAMO

CNMI

RATE per 100,000 < 4.0 4.0 - < 8.0

Figure IV-8. Reported Incidence of Hepatitis B Per 100,000 Population, United States, 1995

Source: National Notifiable Diseases Surveillance System
Hepatitis Surveillance 17

IV. National Surveillance for Acute Viral Hepatitis through 1995

Incidence rates have declined in all age-groups from

1989-1995, but the most dramatic occurred in those 15-39

years of age, in whom the number of reported cases has

decreased by more than 50%. The decline in the number

of cases occurring in this age-group accounted for most of

the decline in overall incidence and is primarily attributed

to unexplained reductions in incidence among injection

drug users. The extent to which routine vaccination of

health-care workers has affected the overall declining

incidence of acute hepatitis B among persons 15 to 39

years of age is not known but is thought to be small.

0

5

10

15

20

25

1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995

Year

15-24 yrs

25-39 yrs

40+ yrs

<15 yrs

Figure IV-9. Reported Cases of Hepatitis B, by Age, United States, 1983-1995

Source: National Notifiable Diseases Surveillance System
18 Hepatitis Surveillance

IV. National Surveillance for Acute Viral Hepatitis through 1995

Demographic Characteristics

The demographic profile of hepatitis B cases in 1994 and 1995 was similar to that of previous years.

 60% of reported cases occurred in persons 20-39 years of age.

 The male:female case ratio was 1.6:1

 Non-Hispanic blacks accounted for a higher percentage of total hepatitis B cases compared to

the percentage of this ethnic group in the United States (12%).

1994

N=4,426

1995

N=4,929

CHARACTERISTIC No. %* No. %

Age (Years)

<5 22 0.5 16 0.3

5-9 38 0.9 34 0.7

10-14 55 1.3 60 1.2

15-19 314 7.1 356 7.3

20-29 1,403 31.9 1,427 29.2

30-39 1,326 30.2 1,550 31.7

40-49 691 15.7 796 16.3

50-59 278 6.3 344 7.0

60+ 271 6.2 302 6.2

Sex

Male 2,641 60.3 2,999 61.4

Female 1,737 39.7 1,884 38.6

Race/Ethnicity

White, non-Hispanic 2,391 58.1 2,361 53.6

Black, non-Hispanic 1,263 30.7 1,453 33.0

Hispanic 295 7.2 380 8.6

American Indian or Alaskan Native 51 1.2 58 1.3

Asian or Pacific Islander 114 2.8 153 3.5

Table IV-5. Distribution of Hepatitis B by Age, Sex, and Race/Ethnicity, United States, 1994-95.

* A total of 4,426 and 4,929 cases of hepatitis B were reported to VHSP in 1994 and 1995 respectively; however, this table

excludes patients with missing risk factor data.

Source: Viral Hepatitis Surveillance Program, CDC.
Hepatitis Surveillance 19

IV. National Surveillance for Acute Viral Hepatitis through 1995

Clinical Characteristics

The clinical profile of cases of acute hepatitis B reported in 1994 and 1995 was similar to that reported in

previous years

 Jaundice was reported in approximately 80% of hepatitis B cases.

 Overall, approximately 28% of cases were hospitalized in 1995, a decrease from 30% in 1994.

Hospitalization rates increased with increasing age.

 Death as a result of acute hepatitis B was reported in approximately 1% of cases.

Percentage* of Patients by Age

1994

Total

N=4,426

<1-14

N=115

15-39

N=3,042

40

N=1,240

Jaundice 82.7 70.7 85.0 78.0

Hospitalized for hepatitis 30.1 29.7 27.7 36.2

Death as a result of hepatitis 1.4 1.0 0.8 2.9

1995 N=4,885 N=110 N=3,333 N=1,442

Jaundice 77.7 69.2 81.9 68.3

Hospitalized for hepatitis 27.9 23.3 24.7 35.8

Death as a result of hepatitis 1.1 0.0 0.8 1.9

Table IV-6. Clinical Characteristics of Patients Reported with Hepatitis B, by Age-Group, United States,

1994-1995

* A total of 4,426 and 4,929 cases of hepatitis B were reported to VHSP in 1994 and 1995 respectively; however, percentages in

this table exclude patients with missing data for age (1% of total), jaundice (10%-22% of total), hospitalization (9%-19% of total),

and death (10%-18% of total).

Source: Viral Hepatitis Surveillance Program, CDC.
20 Hepatitis Surveillance

IV. National Surveillance for Acute Viral Hepatitis through 1995

Risk factors

Injection drug use was the predominant known

risk factor reported in 1994 and 1995, followed by

sexual exposures. A total of 4%-5% of cases

reported sexual contact with a person known to be

infected with hepatitis B virus. Another 20% of

case-patients are attributed to other sexual exposures, including 10% who report homosexual activity and 10% who had multiple sexual partners.

Employment in the medical or dental field, blood

transfusions, and dialysis accounted for less than 3%

of cases. The widespread use of hepatitis B vaccine

among health-care workers has reduced their incidence of disease markedly; in 1985, these workers

accounted for 9% of reported cases, compared to

0.8% in 1994-1995.

Although more than one-half of case-patients

reported in 1994 and 1995 denied a recognized exposure, data from the Sentinel Counties study indicate

that most persons who deny a specific exposure

have some lifetime history of high-risk drug or

sexual behaviors.

Percentage† of Patients by Age (Years)

1994 Total <1-14 15-39 40

N = 4,426 N = 115 N = 3,042 N = 1,240

Injection drug use 12.1 4.3 14.1 7.8

Homosexual activity 9.6 6.6 11.3 5.7

Employed in medical/dental field 0.8 6.1 0.8 0.8

Hemodialysis 0.3 0.0 0.3 0.5

Sexual contact of hepatitis B patient 5.0 1.0 5.9 3.2

Household contact with hepatitis B patient 1.5 4.4 1.4 1.5

Other contact with hepatitis B patient 1.1 1.0 1.0 0.8

Multiple sex partners 11.6 2.6 13.8 7.1

Blood transfusion 1.8 1.0 0.6 4.6

Unknown 56.2 73.3 50.7 67.8

1995 Total <1-14 15-39 ≥40

N = 4,929 N = 110 N = 3,333 N = 1,442

Injection drug use 12.9 5.8 15.1 8.4

Homosexual activity 10.7 1.4 12.7 6.7

Employed in medical/dental field 0.6 0.0 0.5 1.1

Hemodialysis 0.3 0.9 0.2 0.6

Sexual contact of hepatitis B patient 4.3 2.7 4.7 3.5

Household contact with hepatitis B patient 1.2 11.8 1.1 0.7

Other contact with hepatitis B patient 1.3 1.8 1.4 1.0

Multiple sex partners 9.5 1.8 11.2 6.1

Blood transfusion 1.6 0.0 0.7 4.0

Unknown 57.5 72.8 52.4 67.6

* Mutually exclusive groups, in decreasing order of most probable source.

† A total of 4,426 and 4,929 cases of hepatitis B were reported to VHSP in 1994 and 1995, respectively. Percentages above

exclude patients with missing risk factor data.

Table IV-7. Epidemiologic Characteristics* of Patients Reported with Hepatitis B, by Age Group,

United States, 1994-95

Source: Viral Hepatitis Surveillance Program, CDC
Hepatitis Surveillance 21

IV. National Surveillance for Acute Viral Hepatitis through 1995

0

100

200

300

400

500

600

700

800

1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995

Year

Number of Cases

Med/Dental

Employment

Homosexual

Activity

Contact with

Hep B

Multiple Sex

Partners

Drug Use

Figure IV-10. Trends in Selected Risk Factors for Males Reported with Hepatitis B, by Mutually

Exclusive Groups, Selected States,* 1983-1995

0

50

100

150

200

250

300

350

400

1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995

Year

Number of Cases

Drug Use

Med/Dental

Employment

Multiple Sex

Partners

Contact with

Hep B

Figure IV-11. Trends in Selected Risk Factors for Females Reported with Hepatitis B, by Mutually

Exclusive Groups, Selected States,* 1983-1995

* Cases from 15 selected states with high reporting levels

Source: Viral Hepatitis Surveillance Program, CDC
22 Hepatitis Surveillance

IV. National Surveillance for Acute Viral Hepatitis through 1995

Men

 Among men, the number of cases associated with injection drug use decreased by 85% from 1989 to 1993,

but increased from 1993 to 1995.

 The number of cases associated with male homosexual activity declined by more than 50% from 1983 to

1992, but has increased from 1993 to 1995.

 Cases among men attributable to exposure to an HBV-infected contact remained stable in the early 1990s

after declining in the late 1980s. For these cases, 57% of contacts were sexual and 19% were household

contacts.

 A decline in cases associated with health-care employment that began in the mid-1980s continued through

1992 but has since stabilized.

Women

 The number of cases associated with injecting drug use among women, which declined approximately 70%

from 1989 to 1991, has remained stable from 1993 to 1995.

 Cases among women associated with exposure to an HBV-infected contact and with multiple sexual partners have declined through 1993 but have since plateaued.

 The number of cases associated with medical or dental employment has declined more sharply among

women than among men since 1989.
Hepatitis Surveillance 23

Hepatitis C/NANB Hepatitis

The Sentinel Counties Study of Acute Viral Hepatitis,

which has provided the only accurate surveillance data for

monitoring incidence of acute hepatitis C, has shown a

more than 80% decline in incidence from 1989 to 1995

(above). State reporting of hepatitis C cases to NNDSS

(see Table IV-1) has been unreliable for monitoring the

incidence of newly acquired hepatitis C because many of

the cases reported do not meet the case definition for

acute disease. This has occurred because most health

departments do not have the resources required for case

investigations to determine if anti-HCV-positive laboratory reports received represent acute infection, chronic

infection, repeated testing of a person previously reported,

or a false-positive test result.

0

2

4

6

8

10

12

14

16

18

20

82 83 84 85 86 87 88 89 90 91 92 93 94 95

Year

Cases per 100,000 Population

Decline among

transfusion recipients

Decline among

injection drug users

Surrogate testing

of blood donors

Anti-HCV test

(1st generation)

licensed

Anti-HCV test

(2nd generation)

licensed

Figure IV-12. Estimated Incidence of Acute Hepatitis C, United States,1982-1995

Source: Sentinel Counties
24 Hepatitis Surveillance

IV. National Surveillance for Acute Viral Hepatitis through 1995

Demographic characteristics

The demographic profile of cases in 1994 and 1995 was similar to that in previous years:

 Persons 20-49 years of age accounted for >75% of cases in 1994 and 1995.

 The male:female ratio for reported cases was 1.5:1

 Non-Hispanic whites accounted for over 65% of reported cases.

1994

N=954

1995

N=961

CHARACTERISTIC No. %* No. %*

Age (Years)

<5 5 0.5 7 0.7

5-9 10 1.1 5 0.5

10-14 7 0.7 9 0.9

15-19 31 3.3 37 3.9

20-29 179 18.9 170 17.8

30-39 367 38.7 343 35.7

40-49 198 20.8 228 23.7

50-59 73 7.7 62 6.5

60+ 79 8.3 96 10.0

Sex

Male 531 56.2 569 59.2

Female 414 43.8 381 39.6

Race/Ethnicity

White, non-Hispanic 603 68.5 596 65.6

Black, non-Hispanic 156 17.7 174 19.1

Hispanic 88 10.0 94 10.3

American Indian or Alaskan Native 16 1.8 27 3.0

Asian or Pacific Islander 17 1.9 18 2.0

Table IV-8. Reported Cases of Hepatitis C/NANB by Age, Sex, and Race/Ethnicity, United States,

1994-1995

* A total of 954 and 961 cases of hepatitis C/NANB were reported to VHSP in 1994 and 1995 respectively; however, patients with

missing risk factor data are excluded here.

Source: Viral Hepatitis Surveillance Program, CDC.
Hepatitis Surveillance 25

IV. National Surveillance for Acute Viral Hepatitis through 1995

Clinical Characteristics

Hospitalization rates are higher than for hepatitis A,

and similar to rates for hepatitis B. However, hospitalization rates for all cases of viral hepatitis reported to VHSP

are 10%-20% higher than those reported for cases in the

Sentinel Counties, suggesting that VHSP reporting may

be biased toward more severe cases. Case-fatality rates

are also slightly higher than for hepatitis A and B.

Percentage of Patients By Age (years)*

1994

Total

N=954

<1-14

N=22

15-39

N=576

40

N=349

Jaundice 68.1 72.2 69.9 64.7

Hospitalized for hepatitis 32.6 23.8 28.7 39.5

Death as a result of hepatitis 2.4 0.0 2.0 3.1

1995 N=961 N=21 N=550 N=386

Jaundice 62.2 42.1 65.5 58.5

Hospitalized for hepatitis 34.2 44.4 28.5 41.9

Death as a result of hepatitis 1.9 0.0 1.2 3.0

Table IV-9. Clinical Characteristics of Patients Reported with Hepatitis C/Non-A, Non-B Hepatitis,

by Age Group, United States, 1994-1995

* A total of 954 and 961 cases of hepatitis C/NANB were reported to VHSP in 1994 and 1995 respectively; however, percentages

exclude patients with missing data for age (1% of total ), jaundice (7%-14% of total), hospitalization (6%-12% of total), and death

(6%-7% of total).

Source: Viral Hepatitis Surveillance Program, CDC.
26 Hepatitis Surveillance

IV. National Surveillance for Acute Viral Hepatitis through 1995

Risk factors

Injection drug use was the most commonly reported

risk factor among the cases for whom a risk factor was

identified, accounting for approximately one-fourth of

reported cases. Another 10% of cases are attributed to

sexual exposures including having had multiple sex partners (approximately 6%) or having had sexual contact

with a person known to be infected with HCV. Although

more than half of cases in both 1994 and 1995 denied a

recognized exposure, data from the Sentinel Counties

study (see Figure IV-14) indicate that most persons identifying no specific exposure have some lifetime history of

high-risk drug or sexual behaviors.

Percentage† of Patients By Age (years)

1994 Total <1-14 15-39 40

N = 947 N = 22 N = 576 N = 349

Blood transfusion 3.6 6.7 2.1 5.9

Injection drug use 21.9 0.0 28.2 12.9

Employed in medical/dental field 4.9 0.0 3.5 7.5

Hemodialysis 0.5 0.0 0.0 1.4

Sexual contact of hepatitis C/NANB patient 2.4 0.0 3.5 0.9

Household contact with hepatitis C/NANB patient 1.0 4.6 1.4 0.0

Other contact with hepatitis C/NANB patient 0.7 0.0 0.7 0.9

Multiple sex partners 5.7 4.6 7.6 2.6

Unknown 59.3 84.1 53.0 67.9

1995 Total <1-14 15-39 40

N =957 N = 21 N = 550 N = 386

Blood transfusion 5.1 0.0 2.7 87.8

Injection drug use 26.4 0.0 32.2 19.3

Employed in medical/dental field 0.8 0.0 2.4 3.7

Hemodialysis 0.7 0.0 0.4 1.3

Sexual contact of hepatitis C/NANB patient 3.8 0.0 3.8 2.3

Household contact with hepatitis C/NANB patient 0.8 9.5 0.9 0.3

Other contact with hepatitis C/NANB patient 0.6 0.0 0.9 0.3

Multiple sex partners 6.4 0.0 9.3 2.1

Unknown 55.4 90.5 47.4 61.9

* Mutually exclusive groups in decreasing order of most probable cause.

† A total of 954 and 961 cases of hepatitis C/NANB were reported to VHSP in 1994 and 1995 respectively; however, percentages

exclude patients with missing risk factor data.

Table IV-10. Epidemiologic Characteristics* of Patients Reported with Hepatitis C/Non-A, Non-B

Hepatitis, by Age Group, United States, 1994-95

Source: Viral Hepatitis Surveillance Program, CDC
Hepatitis Surveillance 27

IV. National Surveillance for Acute Viral Hepatitis through 1995

Injection drug use has remained the most commonly reported risk factor for hepatitis C/NANB, despite a

more than 55% reduction in number of cases from 1983 to 1993. Transfusion-associated cases have declined

dramatically from 1985 to 1993.

0

50

100

150

200

250

300

1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995

Year

Number of Cases

Drug Use

Blood Transfusions

Med/Dental

Employment Multiple Sex

Partners

Contact with

Hep C/NANB

Figure IV-13. Trends in Selected Risk Factors for Patients Reported with Hepatitis C/NANB, by

Mutually Exclusive Groups, Selected States,* 1983-1995

* Cases from 15 selected states with high reporting levels

Source: Viral Hepatitis Surveillance Program, CDC
28 Hepatitis Surveillance

IV. National Surveillance for Acute Viral Hepatitis through 1995

Other High Risk (20%):

14% Drug Related

4% History of sexually transmitted disease

2% Prison

*8% low socioeconomic status

Sexual (17%)

Unknown * (10%)

Occupation (4%)

Transfusion (3%)

Household (3%)

Injection Drug Use (43%)

Figure IV-14. Risk Factors Associated with Reported Cases of Acute Hepatitis C in Sentinel

Counties, United States, 1983-1995

Source: Sentinel Countries
Hepatitis Surveillance 29

Methods and Notes

Year

1994 1995

Reports submitted on Form CDC 53.1 12,722 11,505

Reports submitted electronically as extended NETSS** records 7,075 10,569

Total cases reports submitted to VHSP 19,797 22,074

Total cases serologically confirmed 17,132 20,755

Total cases meeting case definition for acute hepatitis 16,937 19,905

Symptomatic hepatitis A 11,569 14,026

Symptomatic hepatitis B 4,242 4,715

Hepatitis A and B co-infection 172 203

Symptomatic C/non-A, non-B hepatitis 954 961

Total cases reported to NNDSS* 47,227 46,963

Hepatitis A 29,796 31,582

Hepatitis B 12,517 10,805

Hepatitis C/non-A, non-B 4,470 4,576

Hepatitis, unspecified 444 †

* National Notifiable Diseases Surveillance System

**National Electronic Telecommunications System for Surveillance

† No longer reported as of 1995

Table IV-11. Cases Reported to Viral Hepatitis Surveillance Program Compared with NNDSS, by

Type of Submission, 1994-1995

81% - 100% 61% - 80% 41% - 60% 21% - 40% 0% - 20%

Arkansas Alabama Florida Arizona Alaska

Kansas Connecticut Iowa Colorado California

Maryland District of Columbia Michigan Georgia Idaho

Montana Delaware Minnesota Hawaii Kentucky

Oklahoma Illinois Missouri South Carolina Mississippi

Rhode Island Indiana North Carolina Tennessee New Jersey

South Dakota Louisiana North Dakota Wyoming New York City

Utah Maine Nebraska Oregon

Vermont Massachusetts Nevada Texas

New Hampshire New Mexico

West Virginia New York

Ohio

Pennsylvania

Virginia

Washington

Wisconsin

*and other reporting areas: New York City and the District of Columbia

Table IV-12. Proportion of Total Reported Cases Including VHSP Risk Factor Data, by States,* 1995
30 Hepatitis Surveillance

Methods and Notes

Case Definition

Epidemiologic data about reported cases of

acute viral hepatitis are essential for defining the

groups at risk and for monitoring changes in such

groups. Since new disease acquisition is the

event of interest, chronic infections should not be

reported.

In 1990 the VHSP updated the case definition

for acute viral hepatitis to include IgM antibody

to hepatitis B core antigen (IgM anti-HBc) for

improved diagnosis of acute hepatitis B, to clarify

the reporting of NANB hepatitis, and to include

delta hepatitis as a separate diagnostic category.

The clinical criteria remain the same: an acute

case must include an illness with a discrete date

of onset, and jaundice or elevated serum

aminotransferase levels greater than 2.5 times the

upper limit of normal. The serologic criteria used

to distinguish the different types of hepatitis were

as follows: hepatitis A is defined as being positive

for IgM antibody to hepatitis A virus (IgM

anti-HAV-positive); hepatitis B as positive for

IgM anti-HBc-positive (if done) or hepatitis B

virus surface antigen(HBsAg) and negative for

IgM anti-HAV (if done); and NANB hepatitis as

negative for IgM anti-HAV, and also for IgM

anti-HBc (if done) or HBsAg-negative. In

1994-95, 94% of cases had sufficient serologic testing to designate a specific type. Only those

patients with a specific serologic diagnosis were

included in these analyses.

Cases were excluded if they do not satisfy the

criteria for acute viral hepatitis. Among

serologically confirmed cases in 1994-95, 5% of

hepatitis A cases, 11% of hepatitis B cases, and 7%

of NANB hepatitis cases were excluded because

they failed to meet the clinical case criteria.

Compared with hepatitis B patients who fulfilled

the criteria for acute hepatitis, more persons with

hepatitis B who were asymptomatic or had no

date of onset were ≤14 years of age, were

Asian/Pacific Islander, were dialysis patients, or

had histories of blood transfusions or surgery.

Except for age, NANB hepatitis patients not

meeting the case definition showed a similar

pattern. Compared with NANB hepatitis

patients who fulfilled the criteria for acute hepatitis, more persons with NANB hepatitis who were

asymptomatic or had no date of onset were ≥40

years of age, were patients undergoing dialysis,

or had histories of surgery. This pattern, as well

as that for hepatitis B, is consistent with that for

the earlier years. For both hepatitis B and NANB

hepatitis, these findings suggest that these

persons may have been routinely screened for

HBsAg or for antibody to the hepatitis C virus

(anti-HCV), and found to be positive without any

evidence of acute illness.

Hepatitis A and B coinfections were examined

in the 1995 data, and constituted approximately

1% of cases meeting the case definition. These

cases displayed no specific clustering or associations with geographic or demographic factors.

For purposes of risk factor analysis, these cases

were counted twice, and were included as hepatitis A cases and hepatitis B cases.
Hepatitis Surveillance 31

Appendix: State and Territorial Epidemiologists and

Laboratory Directors

State and Territorial Epidemiologists and Laboratory Directors are acknowledged for their

contributions to hepatitis surveillance programs.. The epidemiologists and laboratory directors listed below were in the positions shown as of October 1996.

State/Territory Epidemiologist Laboratory Director

Alabama John P. Lofgren, MD William J. Callan, PhD

Alaska John P. Middaugh, MD Gregory V. Hayes

Arizona Robert W. England, Jr. MD, MPH Barbara J. Erickson, PhD

Arkansas Thomas C. McChesney, DVM Michael G. Foreman

California Stephen H. Waterman, MD, MPH Michael G. Volz, PhD

Colorado Richard E. Hoffman, MD, MPH Ronald L. Cada, DrPH

Connecticut James L. Hadler, MD, MPH Sanders F. Hawkins, PhD

Delaware A. LeRoy Hathcock, PhD Mahadeo P. Verma, PhD

District of Columbia Martin E. Levy, MD, MPH James B. Thomas, ScD

Florida Richard S. Hopkins, MD, MSPH E. Charles Hartwig, ScD

Georgia Kathleen E. Toomey, MD, MPH Elizabeth A. Franko, DrPH

Hawaii Richard L. Vogt, MD Vernon K. Miyamoto, PhD

Idaho Jesse F. Greenblatt, MD, MPH Richard H. Hudson, PhD

Illinois Byron J. Francis, MD, MPH David F. Carpenter, PhD

Indiana Gregory K. Steele, MD, PhD David E. Nauth (Acting)

lowa M. Patricia Quinlisk, MD, MPH Mary J. R. Gilchristr, PhD

Kansas Gianfranco Pezzino, MD, MPH Roger H. Carlson, PhD

Kentucky Reginald Finger, MD, MPH Thomas E. Maxson, DrPH

Louisiana Louise McFarland, DrPH Henry B. Bradford, Jr, PhD

Maine Kathleen F. Gensheimer, MD, MPH John A. Krueger (Acting)

Maryland Diane M. Dwyer, MD J. Mehsen Joseph, PhD

Massachusetts Alfred DeMaria, Jr, MD Ralph J. Timperi, MPH

Michigan Kenneth R. Wilcox, Jr, MD, DrPH Robert Martin, DrPH

Minnesota Michael T. Osterholm, PhD, MPH Pauline Bouchard, JD, MPH

Mississippi Mary Currier, MD, MPH Joe O. Graves, PhD

Missouri H. Denny Donnell, Jr, MD, MPH Eric C. Blank, DrPH

Montana Todd D. Damrow, PhD, MPH Douglas O. Abbott, PhD

Nebraska Thomas J. Safranek, MD John D. Blosser

Nevada Randall L. Todd, DrPH Arthur F. DiSalvo, MD

New Hampshire Vacant Veronica C. Malmberg, MSN

New Jersey Lyn Finelli, DrPh (Acting) Thomas J. Domenico, PhD (Acting)

New Mexico C. Mack Sewell, DrPH, MS Loris W. Hughes, PhD

New York City Benjamin A. Mojica, MD, MPH Stanley Reimer

New York State Dale L. Morse, MD, MS Ann Wiley, PhD

North Carolina J. Michael Moser, MD, MPH Lou F. Turner, DrPH

North Dakota Larry A. Shireley, MS, MPH James D. Anders, MPH

Ohio Thomas J. Halpin, MD, MPH Kathleen L. Meckstroth, DrPH

Oklahoma J. Michael Crutcher, MD, MPH (Acting) Garry L. McKee, PhD

Oregon David Fleming, MD Michael R. Skeels, PhD, MPH

Pennsylvania James T. Rankin, Jr, DVM, PhD, MPH Bruce Kieger, DrPH

Rhode Island Utpala Bandy, MD, MPH Walter Combs, PhD

South Carolina James J. Gibson, MD, MPH Harold Dowda, PhD

South Dakota Susan E Lance, DVM, MPH Richard S. Steece, PhD

Tennessee William L. Moore, MD Michael W. Kimberly, DrPH

Texas Diane M. Simpson, MD, PhD David L. Maserang, PhD

Utah Craig R. Nichols, MPA Charles D. Brokopp, DrPH

Vermont Vacant Burton W. Wilcke, Jr, PhD

Virginia Grayson B. Miller, Jr, MD James L. Pearson, DrPH

Washington Paul Stehr-Green, DrPH, MPH Jon M. Counts, DrPH

West Virginia Loretta E. Haddy, MA, MS Frank W. Lambert, Jr, DrPH

Wisconsin Jeffrey P. Davis, MD Ronald H. Laessig, PhD

Wyoming Gayle L. Miller, DVM, MPH Roy J. Almeida, DrPH

American Samoa Edgar C. Reid, MO, DSM, MPH —

Federated States of Micronesia Vacant —

Guam Robert L. Haddock, DVM, MPH Florencia Nocon (Acting)

Marshall Islands Tom D. Kijner —

Northern Mariana Islands Jose L. Chong, MD Isamu J. Abraham, DrPH

Palau Jill McCready, MS, MPH —

Puerto Rico Carmen C. Deseda, MD, MPH Jose Luis Miranda Arroyo, MD

Virgin Islands Donna M. Green, MD Norbert Mantor, P